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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881166
Report Date: 12/30/2024
Date Signed: 12/30/2024 03:50:49 PM

Document Has Been Signed on 12/30/2024 03:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TRANQUILITY VALLEY ASSISTED LIVINGFACILITY NUMBER:
331881166
ADMINISTRATOR/
DIRECTOR:
FUENTES, TERESAFACILITY TYPE:
740
ADDRESS:26450 HELENE DRIVETELEPHONE:
(951) 807-3397
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 6DATE:
12/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:David Pakpahan, Care StaffTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced case management visit to the facility to follow up on corrective measures put in place relating to the safeguarding of personal property of Resident One (R1) and to follow up on the pending change of ownership of the business. The LPA met with care staff, David Pakpahan, and informed him of the purpose for the visit. Administrator, Teresa Fuentes, was notified of the purpose for the visit via telephone.

During a visit to the facility on 11/22/2024, the LPA found, through observation and interviews, that staff were safeguarding the personal property of R1. According to Administrator Fuentes, facility staff were not to be safeguarding resident belongings, specifically they were not to handle their finances. The Administrator reported a lock box would be purchased for R1 so the resident could monitor and handle their own finances. A review of R1's medical assessment revealed the resident does not have the capacity to manage their own funds. R1's Participant Care Plan Summary revealed money management assistance was to be provided. Administrator Fuentes confirmed it is still the policy of the facility to not handle resident's personal property or valuables. Fuentes reported Staff One (S1) was in the process of finding a conservator for R1 to assist with management of their finances. According to Fuentes, S1 reported they would reach out to a conservator by 01/06/2025. During this visit, on 12/30/2024, the LPA verified the lock box to be present at the facility which was storing R1's property and valuables. In addition, the LPA followed up on the pending change of ownership of the business. The Department was first notified of the pending change of ownership by Administrator Fuentes on 03/01/2023; however, an official letter of the intent to close was not provided until 12/04/2024. Administrator Fuentes reported Staff One (S1) and Staff Two (S2) were planning on taking over the business. Fuentes reported S1 and S2 were working on applying for a license; however, an application had not yet been submitted and there was no perspective date of submission. Fuentes agreed to maintain communication with the Department regarding the closure and sale of the business.

This report was reviewed with care staff, David, and a copy was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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